celia bradford on vasospasm after sah
DESCRIPTION
Celia Bradford talks about prevention and management of vasospasm after subarachnoid haemorrhage. This talk was recorded at Bedside Critical Care Conference 4.TRANSCRIPT
PREVENTION
AND
MANAGEMENT
Vasospasm After SAH
Prevalence
0.5% of the population will rupture a cerebral aneurysm
25% of these will die
Death is due to
The initial catastrophic bleed
Rebleeding
Cerebral vasospasm
Vasospasm
70% of patients will have angiographic evidence of spasm following the haemorrhage
30% of these cases will have symptomatic spasm
50% of these will have DIND
VASOSPASM
Delayed cerebral vasospasm typically develops
from 4 to 9 days, though earlier (3 days) or late
(3 weeks) vasospasm may be observed
Does spasm = ischemia?
Not necessarily
Many factors contribute to the development of ischemia and infarction,
distal microcirculatory failure,
Poor collateral anatomy,
genetic or physiological variations in cellular ischemic tolerance
Risks for Spasm
Case
50 year old woman
Sudden onset of headache
ED->CTB; SAH. Ruptured AComA aneurysm
Coiling
Progress
EVD inserted for hydrocephalus
Extubated on day 4.
GCS 14 (eyes to voice) but generally drowsy
On day 8 developed left hemiparesis
Intubated
DSA demonstrated severe bilateral ICA spasm
Balloon angioplasty to RICA and MCA
Intraarterial verapamil and papaverine
Progress
Massive doses of noradrenaline and vasopressin to maintain SBP. ICP high. Thio coma
Angio D9... Severe spasm persists refractory to intraarterial verapamil
CTB; diffuse cerebral oedema. ICPs >30
Decompressive craniectomy
Progress
D10;
Despite decompression, ICP remain at 38.
Unsupportable BP
Therapy ceased
Diagnosis
Neuro exam
DSA
TCD
Transcranial Doppler is reasonable to monitor for the development of arterial vasospasm (Class IIa;Level of
Evidence B). (New recommendation)
Warning Signs
CT Perfusion
A=CBF B=CBV
Perfusion imaging can be useful to identify regions of potential brain ischaemia(Class IIa; Level of evidence B)
Management
Management; 6 point plan
1.Nimodipine
2. Euvolemia
3. Induction of Hypertension
4. Mg
5. Cerebral angioplasty and/or selective intra-arterial
vasodilator therapy
6. Stop the boats
Nimodipine
Level 1 Evidence
Euvolemia and Hypertensing
Choice of fluid
SBP aims
Magnesium
Intra-arterial therapy
Management of other complications due to vasospasm
Hyponatremia... Cerebral salt wasting
Role of euvolemia
Fludrocortisone
3% saline
Choice of fluid
Fever
Independent association with high fever after SAH and poor cognitive outcome
Haemoglobin
Controversial
Lower threshold for transfusion in vasospastic patients
Statins
STASH Trial
Other
Urokinase
Lumbar drainage